American College of Physicians: Internal Medicine — Doctors for Adults ®

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Wednesday, March 19, 2014

Requiem for ABC David

When I first learned to take care of patients in the hospital, as a third year medical student, we used a mnemonic to help us remember what to order when a patient was first admitted. Patients would come in to the hospital from a doctor’s office or from the emergency room and the nurses needed a set of orders to know what to do for the patient. The mnemonic we used was “ABC DAVID.” This is how it worked:
1. Admit: to medical surgical unit
2. Because: diagnosis of congestive heart failure
3. Condition: guarded
4. Diet: sodium restricted
5. Allergies: no known drug allergies
6. Activity (sorry, 2 As): bedrest with bathroom privileges
7. Vital signs: every 4 hours while awake
8. Investigations: chest X-ray, morning labs of chemistry panel and blood count
9. Drugs: digoxin, a diuretic, potassium, a beta blocker, maybe insulin or blood pressure medications, acetaminophen for pain, something mild for sleep, if needed.

It worked pretty well. It did allow me to forget certain things that I really didn’t want to forget, like having the nurses measure accurate intake and output (food, water, IV fluids, poop, pee and vomit), care of catheters or nasogastric tubes, but it made sure that I didn’t forget the main things.

Today I admitted a patient with congestive heart failure and used our hospital’s brand new computerized order entry system with its brand new congestive heart failure admission order protocol. It’s huge compared to ABC DAVID, who seemed like a strapping lad a mere quarter of a century ago. It includes the medications that experts have determined from large studies to be necessary for optimal treatment of congestive heart failure, the tests that must be done to adequately diagnose congestive heart failure, plus the other things that we think should be done on everyone who is admitted to the hospital including vaccination for flu and pneumonia, smoking cessation, prevention of blood clots in the legs, plus numerous medications that patients are felt to need even if they don’t take them at home, including laxatives, sedatives and nicotine replacement. I must use my rudimentary knowledge of hospital billing to characterize the patient as being an inpatient or on observation. End-of-life wishes must be documented. Also, of course, ABC DAVID is buried inside the order set.

Even though the computer has various habits that I find irritating, like wanting medication orders to be written in a specific way and notifying me of medication interactions that I am already aware of or which are of no clinical significance, I was grateful to have a way to remember all of this stuff that is, apparently, important and necessary. My brain is too small to hold all of these orders and even too small to hold a mnemonic large enough to remind me of all of these things. Orders are different, of course, for congestive heart failure and community acquired pneumonia, for hip fractures and bowel obstructions and for exacerbations of chronic obstructive lung disease. If I made room in my mind for all of this stuff, I’m sure I would have to jettison something that is far more precious.

It is concerning, at least a bit, to be so dependent on either a computer or a printed cheat sheet to initiate treatment for patients. Physicians being trained now don’t even have a mnemonic to fall back on, and I imagine that their brains are perhaps like giant card catalogs without any of the books in the library. This, of course, completely labels me as being nearly senile, since card catalogs only exist in primitive societies and old peoples’ memories. (I can still evoke that particular wood and paper smell as I type the words “card catalog.”) But unless physicians become familiar with techniques of advanced memory training like the ancient Greeks used for reciting epic poems, there is just too much to know in medicine. We must walk around with some of the vast amount of information that makes up our field of knowledge in order to deduce things, make connections, create solutions to complex problems, but we need to be selective. It is possible to design orders for each patient based upon disease principles and knowledge of hospital processes, recent research and individual patient characteristics. This might be better for patients, but only if we are in top form as we write them. Patient safety advocates favor order forms, for good reason, since I and my fellow physicians can certainly not guarantee that at any given moment we will be in top form.

As I remember ABC DAVID and the days of simpler medicine, it is with the bittersweet regret that makes the past look preferable to the present regardless of whether that is in any way accurate. I would like medicine to be less complicated, and perhaps it will be if we rein in our excesses. But while patients continue to be on too many powerful medications and too many expensive and potentially hazardous tests and procedures are part of everyday practice I am grateful for preprinted order sheets and even computerized order entry when it’s not too bug infested. I have found ways to be creative and innovative and to personalize my care for patients without excessive hindrance by protocolized treatment for high profile diseases. If the powers that be want me to remember to vaccinate and provide smoking cessation information to my patients as I am submerged in their acute, pressing and life threatening immediate needs, I thank whatever inanimate order generator that will relieve me of that burden.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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